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        <div style='text-align: center;'><h2>亳州市城乡居民医疗保险补偿结算单</h2></div>
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            <div style='float: left;'>补偿机构: <span style='border-bottom: 1px solid black;'>高新区中清医院</span>(盖章)</div>
            <div style='float: right;'>补偿金额单位: 元</div>
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            <table border='1' cellspacing='0' width='780' style='text-align: center; table-layout:fixed;'>
                <tr>
                    <td>患者姓名</td>
                    <td>miss29</td>
                    <td>性别</td>
                    <td>男</td>
                    <td>年龄</td>
                    <td>35</td>
                    <td>个人属性</td>
                    <td>居民</td>
                    <td colspan='2'>联系电话</td>
                    <td colspan='2'>18035261513</td>
                </tr>
                <tr>
                    <td>就医机构</td>
                    <td colspan='3'>高新区中清医院</td>
                    <td>住院号</td>
                    <td colspan='2'>73320</td>
                    <td>身份证</td>
                    <td colspan='4'>612729198605051131</td>
                </tr>
                <tr>
                    <td>户主姓名</td>
                    <td></td>
                    <td colspan='2'>家庭住址</td>
                    <td colspan='4'>重庆市市辖区渝中区</td>
                    <td colspan='2'>医疗证(卡)号</td>
                    <td colspan='2'></td>
                </tr>
                <tr>
                    <td>转诊类型</td>
                    <td colspan='3'></td>
                    <td colspan='2'>是否建档贫困人口</td>
                    <td colspan='2'></td>
                    <td colspan='2'>补偿类型</td>
                    <td colspan='2'>特殊疾病住院</td>
                </tr>
                <tr>
                    <td>入院日期</td>
                    <td colspan='2'></td>
                    <td colspan='2'>是否按病种补偿</td>
                    <td>否</td>
                    <td>是否保底</td>
                    <td></td>
                    <td colspan='2'>大病不合规费用</td>
                    <td colspan='2'></td>
                </tr>
                <tr>
                    <td>出院日期</td>
                    <td colspan='3'></td>
                    <td colspan='2'>单病种定额费用</td>
                    <td colspan='2'></td>
                    <td colspan='2'>城乡居民补偿额</td>
                    <td colspan='2'></td>
                </tr>
                <tr>
                    <td>起付线</td>
                    <td colspan='3'></td>
                    <td colspan='2'>医院承担额</td>
                    <td colspan='2'></td>
                    <td colspan='2'>大病保险补偿额</td>
                    <td colspan='2'></td>
                </tr>
                <tr>
                    <td>总费用</td>
                    <td colspan='3'></td>
                    <td colspan='2'>个人自付额</td>
                    <td colspan='2'></td>
                    <td colspan='2'>医疗救助额</td>
                    <td colspan='2'></td>
                </tr>
                <tr>
                    <td>可报费用</td>
                    <td colspan='3'></td>
                    <td colspan='2'>材料超限自负</td>
                    <td colspan='2'></td>
                    <td colspan='2'>财政兜底额</td>
                    <td colspan='2'></td>
                </tr>
                <tr>
                    <td>诊断</td>
                    <td colspan='3'></td>
                    <td colspan='2'>治疗方式</td>
                    <td colspan='2'></td>
                    <td colspan='2'>其他补偿额</td>
                    <td colspan='2'></td>
                </tr>
                <tr>
                    <td colspan='2'>个人实际补偿额(小写)</td>
                    <td colspan='2'></td>
                    <td>(大写)</td>
                    <td colspan='3'></td>
                    <td colspan='2'>180补偿金额</td>
                    <td colspan='2'></td>
                </tr>
                <tr>
                    <td>开户行</td>
                    <td colspan='3'></td>
                    <td>开户名</td>
                    <td colspan='2'></td>
                    <td>开户账号</td>
                    <td colspan='4'></td>
                </tr>
            </table>
            <div style='margin: 10px 5px; font-size: 10px;'>注: 门诊就诊时"入院日期"即为就诊日期</div>
            <table cellspacing='0' width='780'
                   style='text-align: center; table-layout:fixed; word-wrap:break-word; border-collapse:separate; border-spacing:10px; '>
                <tr>
                    <td>经办人(签字)</td>
                    <td style='border-bottom: 1px solid black;'></td>
                    <td>出纳员(签字)</td>
                    <td style='border-bottom: 1px solid black;'></td>
                    <td>结算日期</td>
                    <td style='border-bottom: 1px solid black;'></td>
                </tr>
                <tr>
                    <td>审核员(签字)</td>
                    <td style='border-bottom: 1px solid black;'></td>
                    <td>负责人(签字)</td>
                    <td style='border-bottom: 1px solid black;'></td>
                    <td>领款人(签字)</td>
                    <td style='border-bottom: 1px solid black;'></td>
                </tr>
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    <div style='font-size: 10px; margin-left: 4px;'>第<br/>一<br/>联<br/>︵<br/>补<br/>偿<br/>机<br/>构<br/>留<br/>存<br/>︶</div>
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